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Newsletters>
Pain in the Elderly
January 11, 2009
Pain in the Elderly
By
Miguel A. Pappolla and David L. Bachman
Department of Neurosciences. Division of Neurology
Medical University of South Carolina
The Problem of Pain in the Elderly
Pain is a significant problem in the geriatric population, conservatively estimated to affect more than 33 million people aged 65 years or older in the USA (1). Studies indicate that up to 50% of community or nursing home elderly residents suffer significant pain problems (2, 3). These results clearly indicate that geriatric patients continue to be under-treated and under-diagnosed for their pain. The results of under-treatment are needless suffering and significant negative emotional and social ramifications for patients and their families. Providing effective pain management to the geriatric patient continues to be a challenge to healthcare professionals.
In evaluating pain in the elderly, one must keep in mind current definitions of acute and chronic pain. Acute pain follows injury to the body and generally disappears when the bodily injury heals. It is often, but not always, associated with objective physical signs of autonomic nervous system activity. Chronic pain, in contrast to acute pain, is accompanied by subtle signs of sympathetic nervous system arousal which must be carefully sought in the examination. The relative scant amount of objective signs may prompt the inexperienced clinician to say the patient does not "look" like he or she is in pain (American Pain Society) 4.
As in other patient populations, chronic pain in the elderly is the result of a dynamic interaction of biological, psychological and cultural factors. Categories of pain include persistent and recurrent (episodic) pain with possible fluctuations in severity, quality, regularity, and predictability. Chronic pain can occur in single or multiple body regions and can involve single or multiple systems. Ongoing nociception can result in a sensitization of the peripheral and central nervous systems to produce neurochemical and neurophysiological changes. The International Association for the Study of Pain (IASP) classifies chronic pain as less than 1 month, 1 to 6 months, and greater than 6 months duration (Task Force on Taxonomy, 1994). Previously, chronic pain was defined as having pain for longer than 6 months. It is now recognized that key elements of chronic pain can be evident much earlier. Chronic pain may include varying amounts of disability, from none to severe, and may be independent of the amount of tissue damage and perceived severity (5). It is important that assessment and treatment strategies be based on these definitions and related dimensions. It is critical that the mind-body dualism be abandoned. This old-fashioned thinking is harmful to patients and leads to overmedication, inappropriate investigations, procedures, and interventions or insufficient acknowledgment of the multidimensional experience of pain.
Assessment
The Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) has designated pain as the "fifth vital sign" and has incorporated the assessment of pain into its standards of practice (6). Acceptable practice parameters require obtaining a comprehensive assessment of the patient’s history either in the inpatient or outpatient setting. The American Geriatrics Society has issued guidelines for helping clinicians perform patient interviews including pain specific psychiatric and social histories, drug regimen review, and cognition (www.americangeriatrics.org). Recommended key points include a comprehensive search for the cause of pain, pain characteristics, and impact of physical and psychosocial function. Pain should be assessed on each encounter, as older adults may be reluctant to report pain. Clinicians should nurture their communication skills honed to the geriatric patient, particularly if cognitive impairment is present. Use synonyms for pain when obtaining information (i.e, burning, aching, soreness, discomfort), use simple tools, scales and questions with yes or no answers. Documentation of behaviors (grimacing, irritability, failure to move an extremity, guarding) should be incorporated into the history including increased vocalizations (moaning, groaning, crying). Finally, obtaining and directing the caregiver to document information in the form of a simple pain diary about recent changes in function, gait, behavior patterns and mood is important. Frequently, in addition to direct observation, the clinician must seek the help of an informed caregiver in evaluating cognitively impaired patients for pain behavior. Often, behavioral problems related to specific activities, such as bathing or dressing, may be manifestations of pain in patients with dementia.
Barriers to Pain Management in the Elderly.
Undertreatment of pain is not restricted to the geriatric population. Studies have demonstrated that children, women, patients with cancer, AIDS, sickle cell disease, and arthritis have been needlessly under-treated for pain; over 35 percent of elderly patients living in nursing homes have inadequate treatment for their pain, based on international standards of the World Health Organization. And elderly minorities, particularly African Americans and Hispanics, are also at substantial risk for untreated pain; differences in access to care and medications and variation in the quality of medical attention play a role. It is thus critical to recognize the presence of several internal pain management barriers affecting healthcare providers. Continuing medical education of healthcare providers to overcome these obstacles to pain management is of utmost importance to achieving optimum pain treatment outcomes. Some of these barriers include:
1-Inadequate assessment of the patient's pain.
Study after study have shown that assessment of pain, acute and chronic, in the outpatient or inpatient setting, is done in a manner inconsistent with practice recommendations (7). For example, millions of elderly patients are hospitalized each year in USA hospitals. One study dealing with surgical elderly patients at 12 hospitals revealed dismal data on pain care. Only 37 percent of 709 elderly patients undergoing surgery (98 percent for repair of hip fracture) had the recommended pain assessment following admission. This is the time period when pain following hip fracture is likely to be high (8)
2-Inadequate recognition of co-morbidities that increase the complexity of the patient’s condition and management. Although it is generally acknowledged that the frequent presence of co-morbidities has a significant impact on treatment selection and outcomes for elderly patients with pain, this issue remains an important and challenging area in geriatric pain management. Measures of co-morbidity require recognition, documentation, and accurate data extraction. Diverse gastrointestinal, neurological or renal conditions, for example, impact the use, adverse event profile or metabolism of drugs commonly used in pain management. Co-morbid conditions can exacerbate altered drug metabolism in the geriatric population leading to relatively common errors in clinical practice. Examples include the frequent use of meperidine, morphine or oxycodone in geriatric patients with or without clinically significant renal impairment. The excretion of active metabolite of morphine, morphine-6-glucoronide in patients with decreased renal function (9), is markedly altered resulting in toxic accumulation. Oxycodone is another frequently prescribed opioid medication that exhibits a greater pharmacodynamic effect in the geriatric patient and should be generally avoided. The accumulation of meperidine metabolite normeperidine is problematic in all patients but particularly in the elderly. Consideration of these factors and selection of alternative agents for pain management in the geriatric population (i.e., hydromorphone) should be routinely implemented in the treatment of acute post-operative or chronic moderate-severe pain refractory to other agents and modalities. Incidentally, meperidine was the most frequently administered opioid (31 percent) in the above mentioned study of elderly patients (8).
3-Reluctance of the clinician or patient to use opioid medications in the appropriate setting for fear of possible addiction.
Many physicians are unwilling to prescribe narcotics, no matter how much a patient suffers. Ignorance plays a major role. Health care providers as well as patients frequently fail to understand the difference between physical dependence, addiction and pseudo-addiction. An addict uses a drug to get high, becomes tolerant and needs increasing amounts to maintain that high. Patients taking narcotics for pain do not get high; they get relief from their pain, and when larger doses are needed, it is usually because their pain has become more intense. Unfortunately, the government, including the FDA, has been ambiguous in its guidelines to physicians regarding the prescribing of chronic opiates. For this reason, many physicians are concerned that they will come under scrutiny if they prescribe opiates for chronic pain (10-12). The official position of the DEA is that it does not intend to restrict practitioners in the usual course of medical practice. Additionally, federal laws and regulations do not set standards as to what constitutes "legitimate medical purpose" or "the usual course of professional practice," the requisite elements of lawful prescriptions under the Controlled Substances Act and DEA regulations. Instead, the DEA relies upon the medical community to make these determinations (13).
When in doubt, primary care physicians and non-pain specialists have an obligation to consult a pain specialist for advice. In the ideal world, pain management specialists and multidisciplinary pain clinics should manage chronic pain. However, reimbursement policies, reduced access to pain facilities, inadequate health insurance or no health insurance for some patients create a world of misunderstandings and false expectations between patients and providers often leading to poor pain management outcomes and under-treatment. In this climate, pain management specialists (who can only infrequently assume continuous care of patients with chronic pain) have an obligation to contribute to the education of other fellow health care providers on how to manage pain. These can be accomplished through diverse forums including CME programs and involvement with their state medical boards (some state medical boards now mandate CME content, such as pain management and end-of-life care). While state laws and regulations vary, most, but not all, are based on the Controlled Substance Abuse Act, which was intended to replace state anti-drug laws with a framework that would be consistent with national drug policy. More than a dozen states have prescription monitoring programs which collect prescribing and dispensing data from pharmacies, review and analyze the data, and disseminate it to appropriate regulatory and law-enforcement agencies (14). At a minimum, pain specialists need to guide (educate) the referring provider by including recommendations on what elements they to document at each patient encounter to meet federal and state guidelines for opiod use. Directions on how to begin and exit opioid therapy should also be included in the pain consult report when appropriate.
Presence of Cognitive Impairment
The presence of significant pain is no less common in elderly patients with dementia than in those patients without significant cognitive impairment. Unfortunately, because of impaired verbal and non-verbal communication, pain is even more severely under-recognized in dementia patients than in cognitively intact patients. In addition, even when dementia patients are able to express the presence of pain, caregivers often assume that they are unable to reliably provide such information. Pautex et al (2006) recently demonstrated that 61% of patients with severe dementia could in fact reliably complete a pain self-assessment scale (15). For those dementia patients who are truly unable to communicate their pain symptoms, more than a dozen clinical pain scales for use by caregivers have been published in the literature (16). These scales have in common that they depend on direct observations of patients’ behaviors during a variety of activities. These behaviors include: grimacing, crying out, defensive behaviors, clinching, tachycardia, and tachypnea.
The astute clinician must also be aware of the most common causes of pain in patients with severe dementia. These include constipation or diarrhea, lodged food particles, contractures, bed sores, urosepsis, pain from prolonged immobility, spasticity/dystonia of muscles, skin rashes, osteoporosis, and bladder dysfunction. Although pain medications may bring temporary relief, treatment of the underlying disorder is essential. Consider consultation with a physical therapist for positioning and mobilization, use of antispasticity drugs or botox treatments, good bowel program with adequate hydration, routine urinalysis with a bladder program including the use of urine acidifying agents such as vitamin C or mendalamine. Because elderly demented patients are extremely susceptible to the side effects of nearly all medications used to treat chronic pain, clinicians should only initiate chronic pain medication after a thorough examination for treatable causes of pain (17).
Conclusions
Geriatric pain presents significant problems both to the patients who suffer from it and the practitioners who are uncomfortable treating it. Pain is modified by individual experiences, concurrent medical conditions, genetics, cultural beliefs, cognitive state, expectations, emotions and memory, making the approach to pain management unique for each individual. This may be particularly true in special populations like children and elderly patients. Older patients who present with pain often have multiple medical problems and potential sources of the pain, making the diagnosis and treatment more difficult. Despite the challenges in treating chronic pain in elderly patients, almost no other symptom so powerfully affects an individual’s quality of life. For this reason, clinicians who treat elderly patients must be willing to take on chronic pain as an integral aspect of their patients’ medical care.
1-Young M. Chronic pain management in the elderly. Patient Care. 2000
2-http://www.brown.edu/Administration/News_Bureau/2000-01/00-118.html Accessed July 15, 2007.
3- Baier RR, Gifford DR, Patry G, Banks SM, Rochon T, DeSilva D, Teno JM.. Ameliorating pain in nursing homes: a collaborative quality-improvement project. J Am Geriatr Soc. 2004;12:1988-1995
4-Freedman GM. Chronic pain: clinical management of common causes of geriatric pain. Geriatrics. 2002;57:36-41.
5- McMahon S., Koltzenburg M.: Wall and Melzack's Textbook of Pain,, 5th Edition.
6- Joint Commission on Accreditation of Healthcare Organizations. Implementing the new pain management standards, 2001. Oakbrook, Illinois.
7-American Geriatric Society (AGS) Panel on persistent pain in older adults. Management of persistent pain in older adults. J Am Geriatr Soc. 2002;50:S205-S224 (Abstract).
8- Titler MG, Herr K, Schilling ML, Marsh JL, Xie XJ, Ardery G, Clarke WR, Everett
LQ. Acute pain treatment for older adults hospitalized with hip fracture: current
nursing practices and perceived barriers. Appl Nurs Res. 2003 Nov;16(4):211-27.
9- Meineke I, Freudenthaler S, Hofmann U, Schaeffeler E, Mikus G, Schwab M, Prange
HW, Gleiter CH, Brockmoller J. Pharmacokinetic modelling of morphine, morphine-3-glucuronide and morphine-6-glucuronide in plasma and cerebrospinal fluid of neurosurgical patients after short-term infusion of morphine. Br J Clin Pharmacol. 2002 ;54:592-603.
10-Von Roenn JH, Cleeland CS, Gonin R, Hatfield AK, Pandya KJ. Physician attitudes and practice in cancer pain management. A survey from the Eastern Cooperative Oncology Group. Ann Intern Med.1993;119:121-126.
11-Portenoy RK. Opioid therapy for chronic nonmalignant pain: clinician’s perspective. J Law Med Ethics.1996;24:296-30.
12-McIntosh H. Regulatory barriers take some blame for pain undertreatment. J Natl Cancer Inst.1991;83:1202-1204.
13-Hutchinson A. Statement of Asa Hutchinson, Administrator, Drug Enforcement Administration, Before the House Committe on Appropriations Subcommittee on Commerce, Justice, State, and Judiciary. Executive Summary. Drug Enforcement Administration [Congressional statement.]. December 11, 2001. Available at: http://www.usdoj.gov/dea/pubs/cngrtest/ct121101.html. Accessed July 15 2007
14-(http://www.fsmb.org/pdf/2004_grpol_Controlled_Substances.pdf; accessed 07-15-07)
15- Pautex S, Michon A, Guedira M, Ermond H, Le Lous P, Samaras D, Michel J-P, Herrmann F, Giannakopoulos P, Gold G. Pain in Severe Dementia: Self-Assessment of Observational Scales. JAGS 2006;54:1040-1045
16- Zwakhalen S, Hames J, Abu-Saad H, Berger M. Pain in elderly people with severe dementia: A systematic review of behavioral pain assessment tools. BMC Geriatrics 2006;6:3.
17- Brenner P. The Experience of Jacob Perlow Hospice: Hospice Care of Patients with Alzheimer’s Disease in Hospice Care for Patients with Advanced Progressive Demenita eds L Volicer and A Hurley. Springer Publishing Co., New York, NY. 1998:257-275
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